The second challenge is that there is a lot of redundancy in the angiogenic pathway. By bevacizumab targeting VEGF, we know that it improves outcomes with the addition of paclitaxel/carboplatin. We know it can be safely used with the addition of pemetrexed/carboplatin. For patients who want exposure to all agents, it is reasonable to expose them to an angiogenic agent at some point.
Is there any logic to exploring the combination of bevacizumab and erlotinib (Tarceva) in these patients?
There have been strategies to combine angiogenic agents and anti-EGFR agents. Cetuximab (Erbitux), which is another monoclonal antibody targeting EGFR, has been added to carboplatin/paclitaxel and bevacizumab. Cetuximab hasn’t gotten FDA approval based on the published data we have so far.
What research has been conducted regarding maintenance strategies?
There have been probably more maintenance strategies tested than people realize. The most commonly tested, large phase III trial maintenance strategy would be the addition of pemetrexed after platinum-doublet chemotherapy. Bevacizumab on its own, however, is a maintenance strategy. When that is added to carboplatin/paclitaxel, bevacizumab is continued as maintenance therapy.
There have also been studies adding bevacizumab with pemetrexed as a maintenance component, and smaller studies with gemcitabine and EGFR TKIs in NSCLC.
What are the biggest challenges with this patient population?
We need to get to that personalized medicine [approach]. Picking out the patient who is going to respond to their chemotherapy with a greater than 75% likelihood would be a huge milestone. We need to continue to decrease the toxicity of the agents that we have, and cost is going to be a big challenge in the future as more agents come through. It is great for patients, but it does add to the healthcare bill.
Will chemotherapy forever be part of the treatment paradigm?
I don't foresee chemotherapy going away. It could be 10 to 15 years from now when we learn how to manipulate the immune system so well that that is the first [drug to go away], and we are able to eradicate cancer. That would be fantastic.
However, with the immune system, the redundancy in cancer, and the ability to mutate, change, and acquire resistance will still leave chemotherapy with an active role in patients with lung cancer.